Abstract
Since the coronavirus disease 2019 pandemic, there has been a rise in the use of telehealth pre-vasectomy consultations. Several studies have demonstrated that the rates of vasectomy completion do not seem to be affected by consultation type, suggesting that a pre-vasectomy physical examination is not necessary for successful procedure completion. While the current research offers a preliminary evaluation of the feasibility of virtual consultations for vasectomy, it has not included patient experiences with the consultation and the procedure. Thus, we evaluated satisfaction, procedural experience, and consultation preferences among patients undergoing vasectomy after either in-person or virtual consultation. Between October 1, 2022 and December 31, 2023, patients scheduled with two fellowship-trained infertility specialists were offered either visit type, with consistent counseling and appointment availability across modalities. Post-procedure surveys assessed satisfaction, pain, consultation preference, and anxiolytic use. Of 169 survey respondents, 40 (23.7%) had virtual and 129 (76.3%) had in-person consultations. Five (4.4%) patients who had an in-person consultation reported they would have preferred to have a virtual consultation. In the virtual cohort, 3 (8.6%) patients would have preferred an in-person consultation. No statistical difference was observed between the groups regarding preference for alternate consultation type (P = 0.39). There were also no significant differences in pain rating or reported comfort with vas manipulation by consultation modality (P = 0.21 and P = 0.17, respectively). Most patients still choose in-person consultations over virtual consultations for vasectomy despite equal availability to both, and patients report similar satisfaction and pain scores regardless of their consultation method. Virtual consultation can be offered without compromising patient experience.
Keywords: reproductive, retrospective studies, sterilization, telemedicine, urologic surgical procedures, vasectomy
INTRODUCTION
Vasectomy is a common and effective method of contraception, with approximately 500 000 procedures being performed by urologists in the USA annually.1,2,3 Vasectomy interest and volume have increased in recent years following changes in federal protection for abortion.4,5 Thus, access to vasectomy services remains imperative, and wider adoption of telemedicine offers improved reach for consultation.
The coronavirus disease 2019 pandemic spurred a rise in the use of telehealth pre-vasectomy consultations, and the rates of undergoing vasectomy do not seem to be affected by consultation type.6,7 High in-office vasectomy completion rates have been demonstrated across patients undergoing virtual and in-person consultations at 97.4% and 98.7%, respectively.8 These recent studies suggest that a physical examination at the time of consultation is not necessary for successful procedure completion. While the current research offers a preliminary evaluation of the feasibility of virtual consultations for vasectomy, it has not included patient experiences with the consultation and the procedure.
We used data from satisfaction surveys of patients undergoing vasectomy at Froedtert and the Medical College of Wisconsin (Milwaukee, WI, USA) to evaluate differences in patient preference and procedure experience by consultation type. We hypothesized that patients following vasectomy would be equally satisfied with their initial consultation modality (i.e., in-person or virtual). Second, we hypothesized that patients who had a virtual consultation would report greater subjective discomfort during vasectomy given the lack of physical examination prior to their procedure.
PATIENTS AND METHODS
Beginning in October 2022, patients scheduled for vasectomy consultation with two fellowship-trained infertility specialists at Froedtert and the Medical College of Wisconsin were offered the option of in-person or telehealth visits. Reasons for preference were not systematically recorded. While video visits were available prior to this, they had not been explicitly offered. Both consultation types were conducted during the same clinic blocks with identical counseling protocols. The waiting time for both visit types was approximately 12 weeks. Vasectomies were scheduled after consultation and were not performed on the same day.
Between October 1, 2022 and December 31, 2023, patients were also offered pre-procedure and post-procedure surveys by clinic or office staff. This was done as a quality assurance initiative for our clinic to assess satisfaction with the consultation or the procedure and to evaluate preferred consultation modality. The full post-procedure survey used in this analysis is provided in Supplementary Table 1. Survey completion was voluntary. Paper surveys were distributed in-person by nursing staff at the time of the consultation or procedure. If a patient was scheduled for a virtual visit, they were sent their survey and appointment information via email by a clinic scheduler. No systematic reminder messages were sent after survey distribution. Procedures were completed in clinic or at the on-campus ambulatory surgical center.
Supplementary Table 1.
Post-procedure survey responses
| Question | Options | n (%) |
|---|---|---|
| 0. Did you take Valium? | 1 – Yes | 71 (43.5) |
| 2 – No | 92 (56.4) | |
| 1. How satisfied were you with the ease of the visit? | 5 – Very satisfied | 166 (98.2) |
| 4 – Somewhat satisfied | 2 (1.2) | |
| 3 – Neutral | 1 (0.6) | |
| 2 – Somewhat dissatisfied | 0 (0) | |
| 1 – Dissatisfied | 0 (0) | |
| 2. How satisfied were you with the procedure environment? | 5 – Very satisfied | 167 (98.8) |
| 4 – Somewhat satisfied | 1 (0.6) | |
| 3 – Neutral | 1 (0.6) | |
| 2 – Somewhat dissatisfied | 0 (0) | |
| 1 – Dissatisfied | 0 (0) | |
| 3. On a scale of 1–10, 1 being no pain and 10 being excruciating pain, what was the highest level of pain you experienced during your procedure? | 1 | 33 (19.5) |
| 2 | 49 (29.0) | |
| 3 | 37 (21.9) | |
| 4 | 11 (6.5) | |
| 5 | 16 (9.5) | |
| 6 | 8 (4.7) | |
| 7 | 13 (7.7) | |
| 8 | 2 (1.2) | |
| 9 | 0 (0) | |
| 10 | 0 (0) | |
| 4. How comfortable were you with the manipulation of the vas during the procedure? | 5 – Very comfortable | 118 (69.8) |
| 4 – Somewhat comfortable | 33 (19.5) | |
| 3 – Neutral | 10 (5.9) | |
| 2 – Somewhat uncomfortable | 8 (4.7) | |
| 1 – Uncomfortable | 0 (0) | |
| 5. How satisfied were you with the explanation of post-operative instructions? | 5 – Very satisfied | 166 (98.2) |
| 4 – Somewhat satisfied | 3 (1.8) | |
| 3 – Neutral | 0 (0) | |
| 2 – Somewhat dissatisfied | 0 (0) | |
| 1 – Dissatisfied | 0 (0) | |
| 6a. If you had a virtual consultation, would you have preferred an in-person consult? | 1 – Yes | 3 (8.6) |
| 2 – No | 32 (91.4) | |
| 6b. If you had an in-person consultation, would you have preferred a virtual consult? | 1 – Yes | 5 (4.4) |
| 2 – No | 109 (95.6) |
Across these two physicians in 2022, there were a total of 8 (1.0%) virtual and 791 (99.0%) in-person consultations, and 687 (86.0%) vasectomies were completed. In 2023, 342 (39.2%) consultations were virtual and 531 (60.8%) were in-person, and 724 (82.9%) vasectomies were completed.
Study cohort and data collection
Our study was registered with the Institutional Review Board at the Medical College of Wisconsin (PRO00049443) in January 2024. All patients provided informed consent at the time of survey completion for their data to be used for quality assurance purposes, and institutional permission to publish the deidentified data was obtained. We conducted a retrospective chart review for patients with completed surveys to identify race, ethnicity, address, age at the time of vasectomy, body mass index (BMI), prior inguinal or scrotal surgical history, number of children, and whether vasectomy was completed under local anesthetic or monitored anesthesia care. All patients were offered oral diazepam 10 mg at the time of vasectomy consultation, and if prescribed, they were instructed to take the medication 1 h prior to the scheduled procedure. Anxiolytic use was disclosed on post-procedure surveys. Patients were excluded from the study if they did not undergo vasectomy (n = 31) or if they had not completed a post-vasectomy survey (n = 118). Study data were collected and managed using REDCap.9 Distance from a patient’s home was estimated through Google Maps using the shortest route by a car from the patient’s ZIP code to our clinic.
Statistical analyses
The primary outcome was the difference in post-vasectomy preference for consultation method between the in-person and virtual groups. This was evaluated by asking patients “if you had a virtual consultation, would you have preferred an in-person consultation?” and “if you had an in-person consultation, would you have preferred a virtual consultation?” The secondary outcomes were differences in post-operative pain rating or reported comfort with the procedure between the in-person and virtual groups. Pain was rated on a 10-point scale (1 = no pain and 10 = excruciating pain). Procedural comfort was evaluated with a Likert-type scale (5 = very comfortable and 1 = uncomfortable). A priori planned subanalyses evaluated differential pain reporting outcomes for obese patients (BMI ≥30 kg m−2) or patients with prior inguinal/scrotal surgical history. For these analyses, undesired pain was defined as pain >6 and undesired discomfort with manipulation of the vas deferens was defined as report of “somewhat uncomfortable” or “uncomfortable”.
Study variables were summarized by medians and interquartile ranges (IQRs) for continuous variables and frequencies and percentages for categorical variables. Continuous variables between groups were compared using the Wilcoxon rank sum test. Fisher’s exact test or Pearson’s Chi-square test was used to compare categorical variables between the two groups, with the exact test selected if at least one expected cell count was below five. Statistical significance was defined as P < 0.05. Patients with incomplete survey data were excluded from the individual analyses. All analyses were performed using R Statistical Software (version 4.4.0; R Core Team 2024, Vienna, Austria).
RESULTS
A total of 169 patients completed post-procedure surveys, of which 76.3% (129/169) had an in-person consultation, while 23.7% (40/169) had a virtual consultation. Of an estimated cohort of 894 eligible patients, the participation rate was 18.9%. There was no difference in age, BMI, race, ethnicity, prior inguinal or scrotal surgical history, child status, or distance travelled to clinic between patients in either consultation type (Table 1). Only one patient who completed the survey had their procedure done under anesthesia due to patient preference. There was a statistically significant difference in anxiolytic use between the cohorts, with 48.0% (59/123) of patients who had in-person consultations reporting use of pre-procedure diazepam versus only 30.0% (12/40) of patients who had virtual consultations (P = 0.046). However, there were no demographic differences between patients based on anxiolytic use (Table 2).
Table 1.
Demographics and clinical characteristics of patients who completed survey after undergoing vasectomy following virtual or in-person consultation
| Demographic and clinical characteristic | In-person (n=129) | Virtual (n=40) | P |
|---|---|---|---|
| Age (year), median (IQR) | 38 (35–41) | 38 (35–42) | 0.77 |
| BMI (kg m−2; missing=9), median (IQR) | 27.6 (25.0–31.6) | 27.7 (25.7–32) | 0.82 |
| Underweight (<18.5), n (%) | 0 (0) | 0 (0) | 0.51 |
| Healthy weight (18.5–24.9), n (%) | 29 (22.5) | 6 (19.3) | |
| Overweight (25–29.9), n (%) | 60 (46.5) | 12 (38.7) | |
| Class I obesity (30–34.9), n (%) | 24 (18.6) | 11 (35.5) | |
| Class II obesity (35–39.9), n (%) | 11 (8.5) | 2 (6.5) | |
| Class III obesity (≥40), n (%) | 5 (3.9) | 0 (0) | |
| Race (missing=4, unknown/refuse to answer), n (%) | 0.63 | ||
| White | 115 (91.3) | 36 (92.3) | |
| Black | 3 (2.4) | 2 (5.1) | |
| Asian | 1 (0.8) | 0 (0) | |
| Other | 7 (5.6) | 1 (2.6) | |
| Ethnicity (missing=3, unknown/refuse to answer), n (%) | 0.69 | ||
| Not Hispanic | 119 (93.7) | 38 (97.4) | |
| Hispanic | 8 (6.3) | 1 (2.6) | |
| Prior inguinal/scrotal surgeries, n (%) | 0.91 | ||
| Yesa | 17 (13.1) | 5 (12.5) | |
| No | 112 (86.8) | 35 (87.5) | |
| Has children, n (%) | 0.25 | ||
| Yes | 112 (86.8) | 38 (95.0) | |
| No | 17 (13.1) | 2 (5.0) | |
| Distance to clinic (mile), median (IQR) | 10 (6–17) | 12 (7–16) | 0.66 |
| Procedure done under monitored anesthesia care, n (%) | >0.99 | ||
| Yesb | 1 (0.8) | 0 (0) | |
| No | 128 (99.2) | 40 (100.0) | |
| Pre-procedure anxiolytic use (missing=6), n (%) | 0.046 | ||
| Yes | 59 (48.0) | 12 (30.0) | |
| No | 64 (52.0) | 28 (70.0) |
a11 patients with inguinal hernia repair, 2 patients with prior torsion, 3 patients with orchiopexy, 3 patients with varicocelectomy, 1 patient with hydrocele aspiration, 1 patient with inguinal hernia repair and contralateral prior radical inguinal orchiectomy, and 1 patient with unspecified scrotal surgery. bDue to patient preference in this case. IQR: interquartile range; BMI: body mass index
Table 2.
Demographics and preferences of patients by anxiolytic use
| Demographics and preferences | Pre-procedure diazepam (n=71) | No pre-procedure diazepam (n=92) | P |
|---|---|---|---|
| Age (year), median (IQR) | 38 (35–41) | 38 (36–41) | 0.4 |
| BMI (kg m−2), median (IQR) | 27.8 (24.9–32.2) | 27.5 (25.4–31.4) | 0.98 |
| Race, n (%) | 0.38 | ||
| White | 63 (90.0) | 84 (94.4) | |
| Black | 2 (2.9) | 2 (2.2) | |
| Asian | 0 (0) | 1 (1.1) | |
| Other | 5 (7.1) | 2 (2.2) | |
| Ethnicity, n (%) | 0.47 | ||
| Not Hispanic | 66 (93.0) | 86 (96.6) | |
| Hispanic | 5 (7.0) | 3 (3.4) | |
| Prior inguinal/scrotal surgeries, n (%) | 0.067 | ||
| Yes | 12 (16.9) | 7 (7.6) | |
| No | 59 (83.1) | 85 (92.4) | |
| Has children, n (%) | 0.53 | ||
| Yes | 64 (90.1) | 80 (87.0) | |
| No | 7 (9.9) | 12 (13.0) | |
| Distance to clinic (mile), median (IQR) | 10 (6–18) | 11 (5–16) | 0.50 |
| Post-vasectomy preference for other consultation type (missing=19), n (%) | 0.29 | ||
| Yes | 2 (3.0) | 6 (7.7) | |
| No | 64 (97.0) | 72 (92.3) | |
| Pain rating score, median (IQR) | 3 (2–4) | 3 (2–4) | 0.81 |
| Reported comfort with vas manipulationa, median (IQR) | 5 (4–5) | 5 (4–5) | 0.78 |
a5=very comfortable, 4=somewhat comfortable. IQR: interquartile range; BMI: body mass index
Following vasectomy, only 5 (4.4%) patients who had an in-person consultation reported that they would have preferred to have a virtual consultation (Figure 1). In the virtual consultation cohort, only 3 (8.6%) patients would have preferred an in-person consultation. No statistical difference was observed between the groups regarding preference for alternate consultation type (P = 0.39). The median postoperative pain rating was 2 out of 10 in patients with an in-person consultation, and the rating was 3 out of 10 with patients who had a virtual consultation (P = 0.21). Both cohorts reported that they were “very comfortable” with manipulation of the vas deferens during the procedure (P = 0.17).
Figure 1.
Patient preferences for alternate consultation type post-vasectomy.
Consultation preference also did not differ by anxiolytic use. In patients who used pre-procedure diazepam, 97.0% (64/66) of these patients reported preferring their chosen consultation type (Table 2). In addition, there was no difference in pain rating or reported comfort with vas manipulation in those using anxiolytics (P = 0.81 and P = 0.78, respectively).
Regarding our subanalyses, 9.4% (5/53) of obese patients reported an undesired pain score during the procedure compared to 13.1% (14/107) of non-obese patients (P = 0.5). There was also no difference in reported discomfort with vas manipulation based on BMI, with 1.9% (1/53) of obese patients reporting undesired discomfort versus 2.8% (3/107) of non-obese patients (P = 0.45). Similarly, there was no difference in pain ratings and reported discomfort in patients with prior inguinal or scrotal surgery. Undesired procedural pain scores were reported in 9.1% (2/22) of patients with prior surgery compared to 14.3% (21/147) of patients without prior surgery (P = 0.74). Undesired discomfort with vas manipulation was reported in 4.5% (1/22) of patients with prior surgery compared to 4.8% (7/147) of patients without prior surgery (P = 0.19).
DISCUSSION
This study demonstrates that patients tend to be satisfied with their initial choice for consultation method prior to undergoing vasectomy. There is also no difference in reported pain scores or discomfort level during the procedure between patients who underwent in-person or virtual consultation. In addition, obesity or prior inguinal/scrotal surgical history does not affect reported procedural pain or comfort. Interestingly, our study revealed that patients who had an in-person consultation had higher rates of pre-vasectomy oral diazepam use compared to those who had a virtual consultation, despite similar counseling between consultation methods. The higher diazepam use among patients with in-person consultations may reflect increased anticipatory anxiety from cues in the clinic environment. Conversely, patients choosing virtual consultations may inherently feel more comfortable with the process. Despite use of anxiolytics, patients did not report differences in procedural pain or discomfort. These results overall suggest that a pre-procedure physical examination does not necessarily set expectations or better prepare patients for undergoing vasectomy.
A survey of vasectomized men assessing preferences for pre-vasectomy consultation performed in-person or by telephone found that if given the choice, most patients would have preferred televisit over in-person consultation.10 However, they surveyed only patients who had undergone a telephone consultation. Our practice patterns would suggest that most patients, even when given the choice, still opt for in-person consultation prior to vasectomy. We found that 95.6% of patients who had an in-person consultation would have chosen this modality again.
Satisfaction with telemedicine has also been evaluated in a survey study of a large cohort of men seen for sexual health, of which vasectomy accounted for 1.2% of patients.11 They found that older patients were significantly less likely to prefer telemedicine visits than younger patients, and with each year of age, the odds of a patient preferring telemedicine decreased (odds ratio: 0.97, P < 0.001). In our cohort, we did not find that patient age or distance needed to travel to clinic affected consultation preference.
Recent studies demonstrating efficacy of telehealth in vasectomy consultations have been addressed by the European Academy of Andrology and American Society of Andrology guidelines on male contraception published in 2023.12 The expert panel suggests that “it is reasonable to perform an initial visit for vasectomy via telehealth, but a physical examination on both sides should be done on the day of vasectomy before initiating the procedure”.12 Our survey results support this recommendation and suggest that patient pain levels and reported comfort during the procedure are not affected by timing of physical examination prior to vasectomy.
This study is limited by its retrospective nature and small sample size, indicating a low survey participation rate. Notably, while 39.2% of the total vasectomy cohort selected a virtual consultation, only 23.7% of respondents represented this group, suggesting possible non-response bias and reduced representativeness. Survey distribution and collection may not have been standard across staff, particularly at the time of the procedures since these were done at two locations. Another limitation is that the survey metric used was not validated to ensure measures were psychometrically sound prior to implementation. In addition, the primary outcome measure relied on post-procedure questions that may have reinforced patients’ initial choices, limiting validity. Since patients experienced only one consultation type, responses comparing preference for virtual versus in-person visits may reflect hypothetical preferences rather than true comparisons, introducing potential recall or response bias. Finally, these data were collected from a single academic center, limiting generalizability.
This study adds to the limited literature comparing patient experiences with in-person versus virtual consultation prior to their vasectomy. Despite equal access, most patients still chose in-person consultations; however, satisfaction, pain scores, and procedural comfort did not significantly differ between groups. These findings suggest that virtual consultations can be offered without compromising patient experience. Future research should explore the reasons behind patients’ consultation preferences in order to better structure the vasectomy consultation process.
AUTHOR CONTRIBUTIONS
MGP performed data entry and management and was responsible for drafting and revising the manuscript. MS contributed to data entry and investigation. JSE contributed to study methodology and analytic approach. YJ performed data analysis and assisted with manuscript writing. AS supervised the data analysis. JIS and PND oversaw study design and hypothesis development, supervised the project, and contributed to manuscript writing. All authors read and approved the final manuscript.
COMPETING INTERESTS
All authors declare no competing interests.
ACKNOWLEDGMENTS
The REDCap electronic database used for this project was supported by the National Center for Advancing Translational Sciences, National Institutes of Health (grant No. 2UL1TR001436). Use of the Clinical Research Data Warehouse was supported by the Advancing a Healthier Wisconsin Endowment at the Medical College of Wisconsin as well as the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health (grant No. UL1TR001436).
Supplementary Information is linked to the online version of the paper on the Asian Journal of Andrology website.
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